APPLICATION FOR MEMBERSHIP
NAME (Last, First, MI): ____________________________________ Male Female
Marital Status: Single Married Maiden Name (if applicable) ___________
HOME ADDRESS _________________________
_________________________ ZIP _________ Home Phone ____________________
BUSINESS ADDRESS:____________________________
___________________________ ZIP ________ Business Phone: ___________________
Please send mail to: Home Business
Date of Birth: ___/____/____
Optometry School Attended: ____________ Graduation Date: ____/____/_____
Original License Date: ___/___/____ State(s) where licensed: _____________________________
Date Entered Active Duty: ___/___/____
IF NOW ON ACTIVE DUTY, PLEASE CIRCLE BRANCH:
USA USN USAF PHS VA Civil Service
IF ASSOCIATE, PLEASE CIRCLE PREVIOUS SERVICE:
IF ASSOCIATE, CURRENTLY: RESERVE NATIONAL GUARD PART TIME VA PART TIME CIVIL SERVICE
PARTIAL PRACTICE MEMBERSHIP: PARTIAL PRACTICE
STATEMENT: I certify that I practice fewer than 20 hours per week in a federal facility and do not have any other optometric work for which I am compensated. I also promise to notify the AFOS Executive Director if my status changes. _____ (please initial)
STUDENT: Service providing scholarship: ____________
If you are eligible to join the AOA through AFOS, were you a previous AOA Member? Yes No If yes, affiliated organization(s) and date(s): ___________________________________________________
REMEMBER: DO NOT SEND DUES PAYMENTS TO THE AOA. Make checks payable to AFOS and send all payments to:
EXECUTIVE OFFICE 411 SWEETGRASS COURT GREAT FALLS, MT 59405-1325
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